Healthcare Provider Details

I. General information

NPI: 1982568838
Provider Name (Legal Business Name): TARA J RENNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1218 SIMLE DR
BISMARCK ND
58501-2981
US

IV. Provider business mailing address

1218 SIMLE DR
BISMARCK ND
58501-2981
US

V. Phone/Fax

Practice location:
  • Phone: 701-323-4600
  • Fax:
Mailing address:
  • Phone: 701-323-4600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number3576
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: